Extended treatment of multimodal cognitive behavioral therapy in children and adolescents with obsessive–compulsive disorder improves symptom reduction: a within-subject design

Background Based on the current state of research regarding the treatment in pediatric obsessive–compulsive disorder (OCD), cognitive behavioral therapy (CBT) (in severe cases with additional pharmacotherapy) is considered as the first-line treatment according to internationally recognized guidelines. Research is mostly based on randomized controlled trials (RCTs; efficacy research). Thus, examined treatment conditions, especially the treatment duration, and patients’ characteristics do not necessarily correspond to those found within routine care. Studies showed CBT packages as a whole to be efficacious, but less is known about the effects of individual CBT components. Furthermore, effects on comorbid symptoms or psychosocial impairment have been often neglected and different rater perspectives have been hardly considered in previous research. Methods This effectiveness study aimed to examine the effects of multimodal CBT in children, adolescents, and young adults (age 6–20 years) with OCD (n = 38) within routine care. Effects on obsessive–compulsive and co-existing symptoms were evaluated in a within-subject design by comparing changes during the assessment phase with 12-week standard treatment and with individually tailored extended treatment. Additionally, within the standard treatment, non-exposure treatment was compared to exposure treatment. Multi-informant assessment was applied, and the analyses included multilevel modeling and t-tests for pre-post comparisons. Results During the standard treatment and extended treatment, obsessive–compulsive symptoms, strain, and functional impairment significantly decreased. Moreover, a significant reduction of overall comorbid symptoms emerged, particularly regarding internalizing symptoms, including anxiety and depression. Comparisons of treatment components indicated that adding exposure with response prevention (ERP) has an additional positive effect. Clinical improvement and remission rates increased considerably when more treatment sessions were provided. Conclusions These results suggest that improvement after an initial 12-week course of treatment may not allow for the prediction of non-responders/non-remitters and for the termination of treatment. Overall, the findings show that results from randomized controlled trials are transferrable to routine care. Trial registration number This study was registered retrospectively at the German Clinical Trials Register (https://drks.de/search/de/trial/DRKS00030050). Supplementary Information The online version contains supplementary material available at 10.1186/s13034-022-00537-z.

was used to measure obsession severity, compulsion severity, and the total OCD severity.
The total OCD severity scale was derived by summing up the responses to items 1-10, and obsession and compulsion severity were derived by summing up the responses to items 1-5 and 6-10, respectively (items 1b and 6b were excluded). Items are rated on a 5-point Likert scale (0-4), with higher scores indicating greater symptom severity. The CY-BOCS-D has shown acceptable and good internal consistency, respectively. Sufficient support for the validity of the CY-BOCS-D has also been found .
Diagnostic Checklist for OCD (DCL-ZWA;Döpfner et al., 2008). The checklist includes OCD diagnostic criteria according to ICD-10 and DSM-IV. OCD was diagnosed with this checklist.
Furthermore, OCD-associated personality traits (eight items) were assessed on a 5-point scale ("0 = none" to "4 = extreme"). As the psychometric properties of this DCL-ZWA scale have not been evaluated so far, internal consistency was examined in the study sample, showing an acceptable result ( = .72).For scale formation, the item values are added up and divided by the number of items.
The OCD-CA is a modified version of the Padua Inventory -Washington State University Revision (PI-WSUR; Burns et al., 1996 / PI-WSUR (German translation); Department for Neuropsychology of the University Hospital Bonn, 2002). It comprises two multidimensional questionnaires, a parent form (6 to 18 years) and a self-report form (11 to 18 years). Both questionnaires include the same 36 items for assessing various obsessions and compulsions on a 5-point scale from 0 (not at all) to 4 (very much). The OCD-CA total scale was used for the analyses. For scale formation, ratings of the items are added up. The OCD-CA was found to be a reliable and valid diagnostic instrument (Adam et al., 2019). Goletz, Adam & Döpfner, 2020). The OCD-related problem list exists in a parent form (children  4 years) and self-report form (adolescents  11 years). At pre-treatment (t0), the therapist completed the OCD-PL together with the patient and parents. Individual obsessions, unpleasant feelings (e.g. anxiety) and compulsions were written down. These individual OCD symptoms were then rated by patient and parents regarding frequency ("0 = not at all" to "4 = very much"), strain ("0 = no problem at all" to "9 = it could not have been worse") and psychosocial impairment in school/job, leisure time and family life ("0 = not all" to "4 = extremely impaired") referring to the last week.

OCD-related problem list (OCD-PL;
To evaluate treatment effects, means of the weekly ratings regarding frequency, strain, and psychosocial impairment were used. Daily Observation (Goletz, Döpfner & Roessner, 2018). This protocol includes columns regarding (1) time, (2) triggering events/obsessions, (3) extent of negative emotions (e.g. anxiety) on a scale from 0 to 100, (4) compulsions, (5) duration in minutes, (6) strain caused by OCD symptoms on a scale from 0 to 100. The OCD symptoms were recorded by patients ( 11 years) and parents separately on one weekday (Daily Observation weekday) and one day at the weekend (Daily Observation weekend) at pre-treatment (t0 and t1) and every treatment week. For the analyses, means of the extent of negative emotions, sum of duration, and means of strain of each rating were used.

Impairment Rating Scale -Parent Report (WFIRS-P, Canadian Attention Deficit
Hyperactivity Disorder Resource Alliance (CADDRA), 2011). The OCD-FL includes 26 items and exists in a parent form (patient  6 years) and a self-report form (patients  11 years), which are constructed analogously to each other. Psychosocial impairment is assessed on a 4-point scale ranging from "0 = not at all" to "3 = very often or very much" with regard to five domains: (1) family, (2) learning & school, (3) life skills, (4) self-concept, (5) social activities.
The total score was used for the analyses. As psychometric properties of the OCD-FL have not been evaluated so far, Cronbach's alpha for the total scale was computed using the study sample. Internal consistencies were good to excellent (self-report form:  = .90, parent form:  = .84).
Youth Self Report -YSR/ 11-18R (YSR; Döpfner et al., 2014) & Child Behavior Checklist/ 6-18R (CBCL;Döpfner et al., 2014). These instruments were originally developed by Achenbach & Rescorla (2001). The self-report (YSR: 112 items; patients  11 years) and parent report (CBCL: 113 items; patients  6 years) assess a range of behavioral and emotional problems in children and adolescents. Each item is rated on a 3-point scale ("0 = not true", "1 = somewhat or sometimes true", "2 = very true or often true"). Items are assigned to two broad-band syndrome scales (externalizing and internalizing problems) and eight syndrome scales (aggressive behavior, anxious/depressed, attention problems, rulebreaking behavior, somatic complaints, social problems, thought problems, withdrawn/depressed) and a total scale. Research has demonstrated good reliability and factorial validity (Döpfner et al., 2014). To evaluate overall comorbid symptoms, the broadband syndrome scales and the total scale were used.

German Symptom Checklists for Anxiety Disorders and Obsessive-Compulsive Disorders
(FBB-/SBB-ANZ; Döpfner et al., 2008). These questionnaires include the same 33 items each, with 31 items assessing anxiety symptoms and two items assessing obsession and compulsion. All items are rated on a 4-point scale ("0 = not at all" to "3 =very much").
Furthermore, the questionnaires each include eight items assessing competences regarding sociability and confidence (scale: competences). Results from psychometric evaluations of the SBB-/FBB-ANZ supported reliability and validity (Döpfner et al. 2008). For the analyses, the total anxiety scale and the competence scale were used.
German Symptom Checklists for Depressive Disorders (FBB-/SBB-DES; Döpfner et al., 2008). The structure, implementation, and assessment are the same as described for the SBB-/FBB-ANZ. The total score scale includes 29 items, and a further eight items asked about competences regarding self-confidence and the ability to enjoy things (scale: competences). Research has yielded good results regarding reliability and validity (Döpfner et al. 2008). For the analyses, the total anxiety scale and the competence scale were used.